Mediation Sports subscription | Vrije Universiteit Brussel

Last Name *

First Name *

Gender *

Male

Female

I'm a student at the *

VUB

Field of Study & year *

Student Number *

Address *

Bank account number (IBAN) *

E-mail *

Cellphone number *

Type Of Subscription *

Membership sportsclub

Turn-up card (at least 10 lessons)

Other

Which Sport is the subscription for? *

Where you a member of this club previously? *

Yes

In which year?

Paid Amount *

Date of Payment *

Upload a copy of your membership card/proof of payment *

Add your file

One file only.
28 MB limit.
Allowed types: gif, jpg, png, txt, pdf, doc, docx, ppt, pptx.

Math question *

2 + 2 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.